| NPI | 1134568181 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: WI 72018) |
| Additional Taxonomies | 2086S0127X Surgery Trauma Surgery (Licence: MI 4301112540) |
| 246Z00000X Specialist/Technologist, Other (Licence: DC 4061) | |
| Enumeration Date | 2013-06-21 |
| Last Update Date | 2019-10-29 |